Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness

Andreas Hagendorff,Andreas Helfen,Jan Knierim,Nicolas Merke,Daniel Lavall,Stephan Stöbe,Roland Brandt,Fabian Knebel,Sebastian Ewen,Ertunc Altiok,Tobias Ruf,Dariush Haghi

doi:10.1007/s00392-021-01841-y

Abstract

The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results.Graphic abstract

Highlights

The most frequently used tool for mitral regurgitation (MR) quantification in clinical practice is “eyeballing” of the colour flow jet area to differentiate between mild and severe MR [1]
Considering clinical symptoms and chronicity of the underlying diseases in relation to the specific echocardiographic findings, an extended MR classification is proposed for primary MR (PMR) and secondary MR (SMR) patients
The grading of MR severity by “eyeballing” and the 2D-PISA method is common in clinical practice, but it often leads to incongruent results with a high interobserver variability

Summary

Introduction

The most frequently used tool for mitral regurgitation (MR) quantification in clinical practice is “eyeballing” of the colour flow jet area to differentiate between mild and severe MR [1]. This practice is primarily explained by its ease of use. While some recommendations advise the use of the 2D-PISA in both central and eccentric jets [3, 16], others advise caution [15] These two mainly used diagnostic features—the colour flow jet area and the 2D-PISA method—are complemented by additional semi-quantitative parameters, which eventuate in the “integrated approach” of MR quantification [3, 5, 6, 16].

Limitations

Summary and conclusion